<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 384001816
Report Date: 10/08/2024
Date Signed: 10/08/2024 01:54:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/30/2024 and conducted by Evaluator Jonathan Tse
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20240930144644
FACILITY NAME:PACIFIC PRIMARY - ORANGE SUN CAMPUSFACILITY NUMBER:
384001816
ADMINISTRATOR:STANCIL, MADONNA-DIRECTORFACILITY TYPE:
850
ADDRESS:1501 GROVE STREETTELEPHONE:
(415) 409-1961
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94117
CAPACITY:75CENSUS: 72DATE:
10/08/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Director, Madonna StancilTIME COMPLETED:
02:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
-Child was left unattended in a classroom.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/8/2024, at approximately 9:00AM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced complaint investigation visit at the facility. LPA met with Director Madonna Stancil (D1) and explained the purpose of the visit. Present during the visit was D1, 21 staff, and 72 preschool age children.

The facility submitted a written incident report to the Regional Office on 10/2/2024 detailing an incident where a child was left unattended in a classroom on 9/18/2024. Based on record review of the incident report, the above allegation was proven to have occurred. Based on interviews, the facility admitted that a child was left unattended in a classroom. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

D1 was informed that a Type A deficiency would be cited today and a $500 civil penalty shall be assessed for a violation of CCR 101229(a)(1). A plan of correction was discussed and agreed upon with D1.
***Continued on Page Two***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 05-CC-20240930144644
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PACIFIC PRIMARY - ORANGE SUN CAMPUS
FACILITY NUMBER: 384001816
VISIT DATE: 10/08/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
***Page Two***
LPA Tse informed facility representative Madonna Stancil that this report dated 10/8/2024 documents one Type A citation which shall be posted for 30 consecutive days as there was immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Tse informed the facility representative to provide a copy of this licensing report dated 10/8/2024 that documents any Type A citations to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

See LIC9099-D for Type A deficiency cited today regarding supervision. Appeal rights were provided and explained to D1.

Exit interview conducted and report was reviewed with Director, Madonna Stancil.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 05-CC-20240930144644
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PACIFIC PRIMARY - ORANGE SUN CAMPUS
FACILITY NUMBER: 384001816
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/18/2024
Section Cited
CCR
101229(a)(1)
1
2
3
4
5
6
7
(1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee has conducted individual staff meetings with involved personnel. Licensee shall conduct a staff meeting that goes over transition procedures, including head counts, name-to-face roll calls, and verbal communication between teachers.
8
9
10
11
12
13
14
Based on record review and interview, the Licensee did not comply with the above by leaving a child without supervision in a classroom. This posed an immediate risk to the health or safety of children in care.
8
9
10
11
12
13
14
The facility shall submit a meeting agenda detailing supervision requirements that are signed by all staff members present during the meeting.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4